I've written before about a murder prosecution in Indianapolis against a woman who swallowed rat poison in a suicide attempt while she was 33 weeks pregnant. If convicted, she would receive a minimum sentence of 45 years in prison, with the possibility of capital punishment. The trial court judge refused to dismiss the charges, and the court of appeals will consider the motion to dismiss next month. Nada Stotland and I wrote about the case in today's Indianapolis Star.

In about two weeks, I'll be filing an amicus brief on behalf of the American College of Obstetricians and Gynecologists, other medical groups, and individuals in support of the motion to dismiss charges. Many professors of medicine, bioethics and law have agreed to participate. Others interested in doing so should contact me at dorentli@iupui.edu

Marcia Angell has kicked off another set of controversies for the pharmaceutical sector intwo recent review essays in the New York Review of Books. She favorably reviews meta-research that calls into question the effectiveness of many antidepressant drugs:

Kirsch and his colleagues used the Freedom of Information Act to obtain FDA reviews of all placebo-controlled clinical trials, whether positive or negative, submitted for the initial approval of the six most widely used antidepressant drugs approved between 1987 and 1999—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. . . .Altogether, there were forty-two trials of the six drugs. Most of them were negative. Overall, placebos were 82 percent as effective as the drugs, as measured by the Hamilton Depression Scale (HAM-D), a widely used score of symptoms of depression. The average difference between drug and placebo was only 1.8 points on the HAM-D, a difference that, while statistically significant, was clinically meaningless. The results were much the same for all six drugs: they were all equally unimpressive. Yet because the positive studies were extensively publicized, while the negative ones were hidden, the public and the medical profession came to believe that these drugs were highly effective antidepressants.

Angell discusses other research that indicates that placebos can often be nearly as effective as drugs for conditions like depression. Psychiatrist Peter Kramer, a long-time advocate of anti-depressant therapy, responded to her last Sunday. He admits that “placebo responses . . . have been steadily on the rise” in FDA data; “in some studies, 40 percent of subjects not receiving medication get better.” But he believes that is only because the studies focus on the mildly depressed:

It has long been suspected that July is not a good time to seek medical care at a teaching hospital as new trainees join the care teams. Dr. John Young and colleagues writing in the Annals of Internal Medicine, here, demonstrate this is no myth. Such "cohort turnover" does indeed lead to the chillingly labelled "August killing season." Concentrating on what the researchers viewed to be high-quality studies they found considerable correlation between cohort turnover and increased mortality. A similar negative picture emerged with regard to increased hospital stays, hospital bills and other efficiency metrics. How do we fix this? The researchers suggest looking at workload burdens during the turnover and also staggering the way the cohorts move in and out of the system. So, there's another one to add to the process reform list. [NPT]

I am your guest blogger for July. I will be blogging from South of the Border – precisely from Puerto Vallarta, Jalisco, Mexico. My major topic in my guest blog will be health care in Mexico. There is much to learn from colleagues south of the border.

Mexico has a relatively advanced health care sector with morbidity and mortality patterns of modern industrialized countries. While there is still poverty in Mexico, with persistence of diarrheal and other infectious disease indicative of third world countries, there is greatly increasing morbidity and mortality from coronary artery disease, diabetes and other chronic diseases that plague more developed countries. See World Health Organization, Country Cooperation Strategy: Mexico (2006). Indeed, Mexico is now experiencing a tremendous epidemic of diabetes. Elizabeth Barclay, In Mexico, Diabetes Strains Lives and Budgets, New York Times, June 12, 2007.

Mexico's social security system provides direct health care services to about 50 percent of the population who work or have a family member who work in the formal economic sector. The Mexican Institute of Social Security (Instituto Mexicano de Seguro Social (IMSS)) covers approximately 80 percent of these private sector beneficiaries. The Institute of Security and Social Services for State Workers (Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (ISSSTE)) covers government workers and accounts for 17 percent of the beneficiaries. There are separate systems that provide health coverage and care sponsored by the Secretariat of National Defense (Secretaría de Defensa Nacional), the Secretariat of the Navy (Secretaría de Marina), and Mexican Petroleum (Petróleos Mexicanos (Pemex)). These programs are financed with contributions from employees, employers, and/or government. See Tim L. Merrill and Ramón Miró (ed.), Mexico: A Country Study. Washington: GPO for the Library of Congress (1996).

In 2003, the Mexican Congress amended the Ley General de Salud to establish the System for the Social Protection in Health (SPSS) for the uninsured population who were not otherwise eligible for coverage under IMSS or ISSSTE. Ley General de Salud [The General Law of Health], as amended, art. 18, Diario Oficial de la Federación [D.O.], 7 de Febrero de 1984 (Mex). The reform includes the Seguro Popular (SP), which is a health insurance scheme financed jointly by the federal government and the states. SP will expand health care coverage to the entire population of Mexico by 2012, starting with the poorest families. Specifically, the reform includes five actions: (1) legislation establishing entitlement to coverage for eligible families; (2) creation of explicit benefits packages; (3) funds to state ministries of health in proportion, calculated on the basis of eligible families within the state; (4) division of federal resources flowing to states into separate funds for personal and non-personal health services; and, (5) creation of a fund to protect families against catastrophic health expenditures.

In 2009, Mexico had an uninvited opportunity to showcase its public health and health care delivery capabilities in the H1N1 flu pandemic of 2009. That spring, Mexico experienced outbreaks of influenza-like illness (ILI). On April 12, 2009, Mexico confirmed an outbreak of ILI occurred in La Gloria in the state of Veracruz and reported this outbreak to the World Health Organization (WHO). Later in April, outbreaks of severe pneumonia in Distrito Federal (Mexico City) and San Luis Potosi precipitated increased surveillance throughout the country. The high fatality rate of the novel influenza A (H1N1) infection among younger, previously healthy people was particularly disturbing.

The WHO announced that this outbreak of influenza A (H1N1) virus in Mexico and the United States marked the beginning of a worldwide pandemic. Mexico reacted quickly and aggressively in its surveillance and social distancing measures. The Mexican government cooperated immediately with international health organizations and neighboring countries to address the flu outbreak. By mid- April, the Mexican government issued a national epidemiologic alert to all influenza-monitoring units and hospitals asking that they test and report all cases of severe respiratory illness. On April 24, the government ordered that all schools and large public gatherings, such as soccer games in Mexico City and surrounding areas, be closed or suspended for about ten days. By May, Mexican authorities reported that the outbreak had likely peaked in late April. WHO publically acknowledged that Mexico had been cooperative and forthright in addressing the influenza A (H1N1) outbreak. World Health Organization, “Influenza-Like Illness in the United States and Mexico,” April 24, 2009. Mexico’s decisive actions did much to mitigate the spread of the H1N1 flu pandemic throughout the world.

In my next blog entry, I am going to talk more about Mexico’s efforts to extend universal coverage for all its citizens being with the poorest. The third blog entry will address portability of health insurance across the borders and will focus on making Medicare fully portable. The final blog entry will assess the impact of the North American Free Trade Agreement (NAFTA) on the Mexican health care sector.

We are very pleased to welcome our Guest Blogger for July, Eleanor D. Kinney. Here is her bio:

Eleanor D. Kinney is the the Hall Render Professor of Law Emeritus and founding director of the William S. and Christine S. Hall Center for Law and Health at Indiana University School of Law – Indianapolis. She is also an adjunct professor in the Schools of Medicine and Public and Environmental Affairs. A widely published author and respected lecturer on the subjects of America’s health care system, medical malpractice, health coverage for the poor, and issues in administrative law, Professor Kinney is author or co-author of numerous law review articles, peer-reviewed health policy articles, book chapters and book reviews. She recently published Protecting American Health Care Consumers (Duke University Press 2002) and edited the Guide to Medicare Coverage Decision-Making and Appeals (ABA Publishing 2002).

Professor Kinney received her J.D. and B.A. (with distinction in history) from Duke University. She also has a masters degree in public health from the University of North Carolina – Chapel Hill and a masters degree in European history from the University of Chicago. After graduating from law school, she practiced law for four years at Squire, Sanders & Dempsey in Cleveland, Ohio and then worked as an estate planning officer for Duke University Medical Center. After earning her master’s degree in public health, she served as program analyst for the U.S. Department of Health and Human Services in Washington, D.C. She received an award from the DHHS Office for Civil Rights for Distinguished Performance on the New York City Health and Hospitals Corporation Investigation for 1979‑1980. Before joining the IU faculty in 1984, she was Assistant General Counsel of the American Hospital Association.

Professor Kinney has served as a consultant to the Administrative Conference of the United States, President Clinton’s Task Force for Health Care Reform, and the Indiana Commission on Health Care for the Working Poor. She has been appointed by the governor of Indiana to the Executive Board of the Indiana State Department of Health and to other task forces and advisory boards. During 1999-2000, Professor Kinney was a Fulbright Fellow at the National University of La Plata in La Plata, Argentina. In 2005-2006, Professor Kinney served as Chair of the American Bar Association's Section on Administrative Law and Regulatory Practice and was inducted as a fellow of the Section in 2007.

In 2010, she received the Jay Healey Award for Excellence in Teaching, Health Law Professor’s Section of the American Society for Law, Medicine and Ethics. In 2022, she received the IUPUI Senior Woman’s Leadership Award. In 2000, she received Distinguished Alumna Award for Lifetime Achievement from her alma mater, Emma Willard School. In 1986, she was awarded the Best New Professor Award by the Student Bar Association of Indiana University School of Law – Indianapolis. Professor Kinney is a member of the American Law Institute.

Professor Kinney’s current research interests focus on the realization of the international human right to health, free trade policy and health care, improved administrative law and procedures for a reformed health law system and an improved system for the resolution of medical malpractice claims.

A few months ago predicting the actual date for the announcement of the ACO proposed rule, here, was (almost) as exciting as awaiting a new product announcement from Apple. Well, just as Apple spoiled "Christmas" the other month by pre-announcing the contents of a Steve Jobs product presentation, so Secretary Sibelius, here, has told us that the Exchanges rule is being published today with a summary that somewhat desperately tries to make them appear more user-friendly than the frankly geeky mechanisms they truly are. There are some good resources for the Exchanges newbie, including Julie Appleby's March primer in the Washington Post, here and Sarah Kliff writing for Politico, here. For more detail I recommend Jon Kingsdale and John Bertko writing in Health Affairs, here and, of course, the masterful Tim Jost writing for the Commonwealth Fund, here. Update, HHS site now has Exchanges overview plus links to NPRMs, here. [NPT]